CUSTOMER IDENTIFICATION FORM
(USA Patriot Act Section 326)
Borrower’s Name: ____________________________________________
Residential Street Address:_____________________________________________________
To help the government fight the funding of terrorism and money laundering activities, Federal law requires us to obtain, verify, and record information that identifies each person who applies for financial services from The Fuller Center for Housing. We will ask for your name, address and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
For persons without a SSN/TIN, the ID number must be from one of the following: passport, alien ID card, or any other government issued document issued document evidencing nationality or residence and bearing a photograph or similar safeguard. At least two forms of identification must be presented and documented. For applications taken in person, at least one “Primary” form of ID must be used. For all other applications, any combination of Primary and Secondary Ids may be used. Complete a separate form for each Borrower.
Primary Forms of ID – must display Borrower’s Name Document Country/State of Origin
ID Number___________________________________________
Date of Birth__________________________________________
Expiration____________________________________________
Date________________________________________________
[ ] State Issued Driver License
[ ] State Issued ID Card
[ ] Military ID Card
[ ] Passport
[ ] US Alien Registration Card
[ ] Canadian Driver License
Secondary Forms of ID – must display Borrower’s Name
ID Number___________________________________________
Date of Birth__________________________________________
Expiration____________________________________________
Date________________________________________________
[ ] Social Security Card U.S. Government
[ ] Government Issued Visa
[ ] Birth Certificate
[ ] Non-US/Canadian Driver License
[ ] Most Recent Signed Tax Returns [ ] Fed [ ] State
[ ] Voter Registration Card
[ ] Organizational Membership Card
[ ] Bank/Investment/Loan Statements
[ ] Paycheck stub with name
[ ] Most Recent W-2
[ ] Home/car/renter insurance papers
[ ] Recent utility bill
I certify that I have personally viewed and accurately recorded the information from the documents identified above, and have reasonably confirmed the identity of the applicant.
Fuller Center Representative Signature: ________________________________________
Date: ______________________
Fuller Center Representative Name: ____________________________________________
Helpful hint: If you want to search for a specific topic in the Operations Manual, search for the word “manual” followed by a “+” sign and then a specific term. For example, if you want to know more about hammers, you would search for “manual+hammers”.